An atypical presentation of diffuse midline pontine glioma in a middle age patient: Case report.

INTRODUCTION: Diffuse midline glioma is a newly WHO defined entity (grade IV) (Louis et al., 2016) which includes diffuse intrinsic pontine glioma (DIPG) reported in pediatric population and, occasionally, in young adults. Here, we present a detailed description of an atypical case of diffuse midline glioma in a 53 years old woman. CASE REPORT: A caucasian woman aged 53 from Ukraine, was referred to another neurological department complaining of 3 months history of progressive postural instability and gait impairment with frequent falling. Magnetic resonance demonstrated two brainstem lesions, hyperintense in FLAIR with "patchy" peripheral enhancement, leptomeningeal and cranial nerves enhancement. CSF was normal. Due to positive antinuclear antibodies test (ANA 1:360), intravenous steroid treatment was administered and reported to initially improve the patient condition. However, the following weeks the lady worsened. Imaging features were unchanged. Because quantiferon test resulted positive, MRI-Spectroscopy showed an inflammatory pattern and MRI perfusion study and brain FDG-PET, were normal, tubercolar granulomatous hypothesis was initially favored. Antitubercular therapy with isoniazid, pyrazinamide, ethambutol and rifampicin was started without any clinical improvement. Hence, the biopsy was proposed. The procedure revealed a diffuse midline pontine glioma. Considering the advanced stage of the disease, radiotherapy was not indicated. Patient died after eight months from the onset of neurological disturbances. CONCLUSION: Our case shows that diffuse midline glioma is a CNS tumor not limited to young population but occurring also in middle aged patients with an insidious pattern. We therefore recommend to perform biopsy at very early stages in patients with atypical brainstem lesions.

Assessing the decoupling of economic growth from environmental impacts in the European Union: A consumption-based approach.

Pursuing a responsible and sustainable development, the United Nations urged to decouple economic growth from environmental impacts. Several European Union (EU) policies have been implemented towards such goal. Although multiple authors have evaluated the decoupling of the economic growth from the resource use or environmental concerns, the environmental assessment mostly focused on pressures rather than impacts, and used single indicators assumed to be a proxy of the overall effects on the environment. Furthermore, no studies were found using a process-based life cycle approach to quantify the environmental impacts of consumption. To solve such research gap, this paper assesses the decoupling in the EU focusing on potential environmental impacts, complementing a production-based approach with two options for accounting for the impacts of consumption. The aim of this paper is to evaluate the decoupling of the economic growth (in terms of Gross Domestic Product) from the environmental impacts due to EU-28 consumption, assessed by means of life cycle assessment (LCA). The decoupling is then assessed in impact terms rather than limited to pressures by using the Environmental Footprint (EF2017) indicators, which allows assessing 16 different impacts. The Consumption Footprint indicator quantified the environmental impacts of EU apparent consumption, including the territorial impacts (Domestic Footprint) and the embodied impacts in both imports and exports (Trade Footprint). The inventory of pressures for the trade component is compiled either with a bottom-up approach (process-based LCA of representative traded goods) or a top-down approach (input-output-based LCA). Methodological aspects influencing the decoupling assessment and the resulting outputs are presented and discussed. According to the results, the environmental impacts of EU-28 consumption showed decoupling during the last decades (2005-2014), between relative to absolute decoupling depending on the inventory modeling approach taken. Some countries showed higher decoupling levels than others displaying a heterogeneous map of EU-28 decoupling, which was led by acidification, particulate matter, land use and eutrophication impacts. Notwithstanding current limitations, the assessment of decoupling using consumption-based environmental indicators is very promising for supporting policy-making towards addressing the actual impacts driven by the EU production and consumption system.

Phononic crystals of spherical particles: a tight binding approach.

The vibrational dynamics of a fcc phononic crystal of spheres is studied and compared with that of a single free sphere, modelled either by a continuous homogeneous medium or by a finite cluster of atoms. For weak interaction among the spheres, the vibrational dynamics of the phononic crystal is described by shallow bands, with low degree of dispersion, corresponding to the acoustic spheroidal and torsional modes of the single sphere. The phonon displacements are therefore related to the vibrations of a sphere, as the electron wave functions in a crystal are related to the atomic wave functions in a tight binding model. Important dispersion is found for the two lowest phonon bands, which correspond to zero frequency free translation and rotation of a free sphere. Brillouin scattering spectra are calculated at some values of the exchanged wavevectors of the light, and compared with those of a single sphere. With weak interaction between particles, given the high acoustic impedance mismatch in dry systems, the density of phonon states consist of sharp bands separated by large gaps, which can be well accounted for by a single particle model. Based on the width of the frequency gaps, tunable with the particle size, and on the small number of dispersive acoustic phonons, such systems may provide excellent materials for application as sound or heat filters.

[Nailfold capillaroscopy and blood flow laser-doppler analysis of the microvascular damage in systemic sclerosis: preliminary results]. / Studio della microangiopatia sclerodermia mediante valutazione dinamica con laser-Doppler e morfologica con videocapillaroscopia periungueale: risultati preliminari.

OBJECTIVES: Systemic sclerosis (SSc) is characterized by altered microvascular structure and function. Nailfold videocapillaroscopy (NVC) is the tool to evaluate capillary morphological structure and laser-Doppler Blood flowmetry (LDF) can be used to estimate cutaneous blood flow of microvessels. The aim of this study was to investigate possible relationships between capillary morphology and blood flow in SSc. METHODS: Twenty-seven SSc patients and 12 healthy subjects were enrolled. SSc microvascular involvement, as evaluated by NVC, was classified in three different patterns ("Early", "Active", "Late"). LDF analysis was performed at the II, III, IV, V hand fingers in both hands and both at cutaneous temperature and at 36 degrees C. Statistical evaluation was carried out by non-parametric procedures. RESULTS: Blood flow was found significantly lower in SSc patients when compared with healthy subjects (p<0.05). The heating of the probe to 36 degrees C induced a significant increase in peripheral blood flow in all subjects compared to baseline (p <0.05), however, the amount of variation was significantly lower in patients with SSc, compared with healthy controls (p <0.05). The SSc patients with NVC "Late" pattern, showed lower values of peripheral blood flow than patients with NVC "Active" or "Early" patterns (p<0.05). Moreover, a negative correlation between the tissue perfusion score and the progression of the SSc microangiopathy was observed, as well as between the tissue perfusion and the duration of the Raynaud's phenomenon (p <0.03). CONCLUSIONS: LDF can be employed to evaluate blood perfusion in the microvascular circulation in SSc patients. The blood flow changes observed with the LDF seem to correlate with the severity of microvascular damage in SSc as detected by NVC.

Endothelin and sex hormones modulate the fibronectin synthesis by cultured human skin scleroderma fibroblasts.

OBJECTIVE: To evaluate the influence of endothelin-1 (ET-1) and sex hormones on cell proliferation and extracellular matrix (ECM) synthesis (ie, fibronectin, laminin) by cultured normal and scleroderma (SSc) human skin fibroblasts (FBs). METHODS: Primary cultures of FBs were treated with ET-1 and sex hormones (17beta-oestradiol or testosterone) for 24 h. Cell growth was analysed by methiltetrazolium salt test, ECM synthesis was evaluated by immunocytochemistry and western blot, both at 24 h. RESULTS: In normal FBs, ET-1 and 17beta-oestradiol, as well as their combination, increased cell growth (p<0.001, p<0.001, p<0.01 vs untreated cells (control), respectively) and fibronectin synthesis (p<0.05, p<0.05, p<0.01 vs control, respectively). By contrast, testosterone either alone or in combination with ET-1 did not influence cell proliferation, but decreased fibronectin synthesis (p<0.05, testosterone vs control). In SSc FBs, ET-1 and 17beta-oestradiol alone or their combination induced an increased fibronectin synthesis (p<0.05, p<0.05, p<0.01 vs control, respectively). Unexpectedly, testosterone induced an increase of fibronectin synthesis (p<0.05 vs control). CONCLUSIONS: ET-1 and 17beta-oestradiol seem to exert a profibrotic effect in normal and SSc culture FBs and might suggest their synergistic effect in the pathogenesis of the fibrotic process in SSc.

[Role of videocapillaroscopy in early detection of transition from primary to secondary Raynaud's phenomenon in systemic sclerosis]. / Ruolo della videocapillaroscopia periungueale nella identificazione precoce della progressione del fenomeno di Raynaud da primario a secondario nella sclerosi sistemica.

Patients initially diagnosed as having primary Raynaud's phenomenon (PRP) may shift to secondary (SRP) during the follow-up. Nailfold videocapillaroscopy (NVC) is a tool that allows to distinguish between PRP and SRP through the identification of the "early" scleroderma-pattern of microangiopathy. The aim of this study was to evaluate the transition from PRP to SRP in an Italian cohort of patients during their follow-up. 129 patients with PRP were identified and followed-up for 2721 months. The diagnosis of PRP was achieved as suggested by LeRoy. The NVC diagnosis of scleroderma-pattern was based on the presence of specific "early" capillary abnormalities (i.e. giant capillaries, microhaemorrhages, and/or slight reduction of capillary density). Based on the identification of the "early" scleroderma-pattern by NVC, 14% of patients changed from PRP to SRP during the follow-up. Interestingly, 4.6% of these patients showed at baseline a fully normal NVC pattern (transition from normal to scleroderma NVC pattern in 3427 months), and 10% showed slight and not-specific nailfold capillary abnormalities (i.e. dystrophic capillaries and/or enlarged capillaries) at baseline (transition to scleroderma NVC pattern in 2515 months). Following a careful NVC analysis, we showed the progression from PRP to SRP in 14% of the analyzed patients. We suggest the capillaroscopic analysis twice a year in presence of PRP, in order to early detect the transition to SRP in patients showing at the beginning a normal pattern or not-specific nailfold capillary abnormalities, as assessed by NVC.

Scoring the nailfold microvascular changes during the capillaroscopic analysis in systemic sclerosis patients.

BACKGROUND: Longitudinal study to define a scoring system to quantify the specific capillary abnormalities, as observed by capillary microscopy in systemic sclerosis (SSc). METHODS: Ninety patients with SSc were evaluated by nailfold videocapillaroscopy for an average of 72 (SD 23) months. Enlarged and giant capillaries, haemorrhages, loss of capillaries, disorganisation of the microvascular array, and capillary ramifications were the evaluated parameters identifying the "scleroderma patterns". A semiquantitative rating scale to score these altered microvascular parameters was adopted (score 0-3). A "microangiopathy evolution score" (sum of three scores: loss of capillaries, disorganisation of the microvascular array and capillary ramifications) was also selected to assess the progression of the vascular damage. RESULTS: At the end of the follow-up, the score for each nailfold videocapillaroscopy parameter significantly changed. The microangiopathy evolution score significantly increased in 53 of 90 patients (59%) indicating a worsening of the microangiopathy. On the contrary, 22 patients (24%) showed a significant decrease of the evolution score suggesting an improvement of the microangiopathy and no changes were detected in 15 patients with SSc (17%). CONCLUSIONS: The capillaroscopic score was found to be a sensitive tool to quantify and monitor the SSc microvascular damage. Furthermore, the microangiopathy evolution score might be used to survey the evolution of the microvascular damage, as the relative scores increase during the progression of the SSc.

[Therapy of rheumatic polymyalgia: the pathophysiologic management]. / Trattamento della polimialgia reumatica: l'approccio fisiopatologico.

Polymyalgia rheumatica (PMR) is an inflammatory syndrome affecting older people whose prevalence has increased in recent years. The suppression of the hypothalamic-pituitary-adrenal axis (HPA) and ageing may contribute to the pathogenesis of PMR. Chronic stress (i.e. interpersonal, chronic infections etc.) in elderly people may represent a risk factor for the development of PMR. In fact, elderly represent per se a condition of endocrine senescence including adrenal hypofunction, in addition chronic stress represents a further harmful stimulus to seriously compromise endogenous glucocorticoid production. Synovitis and vasculitis characterize the majority of the patients. Serum cytokine and steroidal hormone patterns suggest that patients with PMR have an intensive inflammatory reaction. As a matter of fact, glucocorticoids represent the most useful temporary "replacement" treatment during the active phase of PMR. The use of modified-release glucocorticoids that might induce higher levels during the night (circadian rhythms as in physiological conditions), will represent another important approach to optimize PMR treatment and reduce the side effects. Combination therapy between glucocorticoids and inhibitors of pro-inflammatory cytokines should be tested in large studies and early cases of PMR.

[Leishmaniasis in rheumatoid arthritis]. / La Leishmaniosi nell'artrite reumatoide.

Leishmaniasis represents a complex of diseases with an important clinical and epidemiological diversity. Visceral leishmaniasis is of higher priority than cutaneous leishmaniasis as it is a fatal disease in the absence of treatment. The clinical spectrum of leishmaniasis and control of the infection are influenced by the parasite-host relationship. The role of cellular immune responses of the Th1 type in the protection against disease in experimental and human leishmaniasis is well established. TNF-alpha has been implicated in cytokine-induced macrophage activation and tissue granuloma formation, two activities linked to control of intracellular visceral infection caused by Leishmania donovani. Anti-tumor necrosis factor-alpha (TNF-alpha) strategies have had a marked and substantial impact in the treatment of rheumatoid arthritis, however the clinical use of TNF-alpha antagonists has been accompanied by increased reporting of infections. Here we report the first case of visceral leishmaniasis in a patient treated for a long period of time with human anti TNF-alpha monoclonal antibody, adalimumab. Due to the low incidence rate of Mediterranean visceral leishmaniasis, a systematic screening for leishmaniasis in all patients treated with biologics may be not recommended. However, for those patients living at high risk of leishmaniasis exposure, a periodical serological monitoring should be performed during therapy with anti-TNF monoclonal antibodies.

[Endothelin-1 in systemic sclerosis]. / Endotelina-1 e sclerosi sistemica.

UNLABELLED: We evaluated endothelin-1 (ET-1) plasma levels in patients affected by primary Raynaud's phenomenon (PRP), as well as in patients with systemic sclerosis (SSc) and secondary Raynaud's phenomenon (SRP). Furthermore, ET-1 levels were investigated in SSc patients with different patterns of peripheral microvascular damage, as evaluated by nailfold videocapillaroscopy (NVC). METHODS: 23 PRP patients, 67 SSc patients according to ACR criteria, and 23 healthy subjects were enrolled. SSc microvascular involvement was classified in three different patterns (Early, Active, and Late) by NVC, as previously described. RESULTS: ET-1 was found significantly higher in both PRP and SRP, when compared with controls (median +/-IQR: 3.3+/-2.8, 2.7+/-2.2, 2.0+/-2.2, respectively) (p=0.05). No statistically significant difference of ET-1 levels was observed between PRP and SRP patients. ET-1 was found higher in patients with Late NVC pattern, when compared with both Active and Early NVC patterns (median+/-IQR: 3.4+/-2.5, 2.4+/-2.2, 2.5+/-2.1, respectively), but without statistical significance. Patients with Late NVC pattern showed significantly higher ET-1 plasma levels than controls (p=0.03). No correlation was found between ET-1 levels and disease duration in both groups, as well as between ET-1 levels and age of patients. CONCLUSIONS: These data support previous studies, reporting increased ET-1 plasma levels in both PRP and SRP patients. Interestingly, patients with the Late NVC pattern of microangiopathy showed higher ET-1 plasma levels than controls. The high levels of ET-1 detected in the Late NVC pattern of microangiopathy might be related to the larger fibrotic involvement typical of the advanced stages of disease.

Nailfold capillaroscopy is useful for the diagnosis and follow-up of autoimmune rheumatic diseases. A future tool for the analysis of microvascular heart involvement?

Raynaud's phenomenon (RP) represents the most frequent clinical aspect of cardio/microvascular involvement and is a key feature of several autoimmune rheumatic diseases. Moreover, RP is associated in a statistically significant manner with many coronary diseases. In normal conditions or in primary RP (excluding during the cold-exposure test), the normal nailfold capillaroscopic pattern shows a regular disposition of the capillary loops along with the nailbed. On the contrary, in subjects suffering from secondary RP, one or more alterations of the capillaroscopic findings should alert the physician of the possibility of a connective tissue disease not yet detected. Nailfold capillaroscopy (NV) represents the best method to analyse microvascular abnormalities in autoimmune rheumatic diseases. Architectural disorganization, giant capillaries, haemorrhages, loss of capillaries, angiogenesis and avascular areas characterize >95% of patients with overt scleroderma (SSc). The term 'SSc pattern' includes, all together, these sequential capillaroscopic changes typical to the microvascular involvement in SSc. The capillaroscopic aspects observed in dermatomyositis and in the undifferentiated connective tissue disease are generally reported as 'SSc-like pattern'. Effectively, and early in the disease, the peripheral microangiopathy may be well recognized and studied by nailfold capillaroscopy, or better with nailfold video capillaroscopy (NVC). The early differential diagnosis between primary and secondary RP is the best advantage NVC may offer. In addition, interesting capillaroscopic changes have been observed in systemic lupus erythematosus, anti-phospholipid syndrome and Sjogren's syndrome. Further epidemiological and clinical studies are needed to better standardize the NCV patterns. In future, the evaluation of nailfold capillaroscopy in autoimmune rheumatic diseases might represent a tool for the prediction of microvascular heart involvement by considering the systemic microvascular derangement at the capillary nailfold.

[Capillaroscopy and rheumatic diseases: state of the art]. / Kapillarmikroskopie und rheumatische Erkrankungen: State of the art.

Nailfold capillaroscopy (NVC) represents the best method for analyzing microvascular abnormalities in rheumatic diseases. Raynaud's phenomenon (RP) represents the most frequent clinical aspect of microvascular involvement and is a key feature of several such diseases. Under normal conditions or in primary RP (exclusion by the cold-exposure test), the normal nailfold capillaroscopic pattern shows a regular disposition of the capillary loops within the nail bed. However, in subjects suffering from secondary RP, one or more alterations in the capillaroscopic findings should alert the physician to search for an underlying connective tissue disease. Architectural disorganization, giant capillaries, hemorrhages, loss of capillaries and avascular areas characterize more than 95% of patients with overt systemic sclerosis (scleroderma, SSc). Therefore, the term "scleroderma pattern", includes all capillaroscopic changes typical of the microvascular involvement in SSc. The capillaroscopic aspects observed in dermatomyositis and in undifferentiated connective tissue disease are generally reported as "scleroderma-like patterns". This peripheral microangiopathy can be effectively detected early in the course of the disease and studied in detail by nailfold capillaroscopy or, better, with NVC. In addition, early differential diagnosis between primary and secondary RP is the greatest advantage NVC has to offer. In addition, interesting capillaroscopic changes have been observed in systemic lupus erythematosus, antiphospholipid syndrome and Sjögren's syndrome. However, further epidemiological and clinical studies are needed to better standardize NVC patterns.

Localized and systemic forms of scleroderma in adults and children .

Systemic sclerosis (SSc) presents a great deal of variability in the extent and severity of skin and internal organ involvement. The diagnostic and prognostic significance of autoantibodies in SSc is undisputed and the patient's autoantibody profile represents a fundamental tool for clinicians. Scleroderma is a rare condition in children. Unlike adults, localized scleroderma is more frequent than the systemic sclerosis, nevertheless it represents a disabling condition. In both conditions, no validated outcome measures and proven effective treatment is available to date.Raynaud's phenomenon (RP) is one the most common and significant clinical symptoms of SSc and therefore in patients with RP a capillaroscopic analysis should be carried out as soon as possible. The actual and select advantage of the early nailfold videocapillaroscopic (NVC) analysis is to distinguish between the primary RP and the secondary RP and to allow the early detection of SSc.

Circannual vitamin d serum levels and disease activity in rheumatoid arthritis: Northern versus Southern Europe.

BACKGROUND: Greater intake of vitamin D has been associated with a lower risk of rheumatoid arthritis (RA) and low serum vitamin D together with higher prevalence of RA seem common among North European people when compared to Southern Europe. OBJECTIVES: To evaluate serum 25-hydroxyvitamin D [25(OH)D] levels in female RA patients from North (Estonia) and South (Italy) Europe and to correlate them with the disease activity score (DAS28) during winter and summer. METHODS: Fifty-four RA Italian patients (IP) and 64 RA Estonian patients (EP) were evaluated for serum 25(OH)D levels in winter and summer time, as well as for DAS28 score. Normal female controls (C) were 35 (IC) and 30 (EC) age-matched subjects, respectively. 25(OH)D concentrations were measured by a competitive radioimmunoassay. Statistical analysis was performed by "r" Pearson correlation, "t" Student with Bonferroni correction and by repeated ANOVA measures (summer and winter) with two factors (country and clinical status). RESULTS: 25(OH)D levels were found significantly higher in IP versus EP (p = 0.0116) both in winter and in summer time. Differences were observed also in controls. The variations (increase) of 25(OH)D levels between winter and summer were found significant (p = 0.0005) in both IP and EP. Differences were observed also in controls. No significant differences were found concerning 25(OH)D levels between RA patients and their controls in either country. Interestingly, a significant negative correlation between 25(OH)D and DAS28, was found in summer only in IP (r =-0.57, p < 0.0001) and in winter in EP (r =-0.40, p < 0.05). CONCLUSION: Significantly lower 25(OH)D serum levels were observed in RA patients from North versus South Europe with a circannual rhythm in winter and summer time. In addition, 25(OH)D values showed a significant correlation (negative) with RA clinical status (DAS28) in both North and South European RA patients, suggesting possible effects of vitamin D among other factors on disease activity.

Lost stones during laparoscopic cholecystectomy.

BACKGROUND: Gallbladder perforation, with loss of calculi in the abdomen is frequent during laparoscopic cholecystectomy. Recent publications report complications in port sites or in the abdominal cavity. A study of 3686 laparsocopic cholecystectomies performed by 6 surgeons was undertaken. In 627 patients, perforation of the gallbladder occurred and in 254 stones were spilled into the abdominal cavity. In 214 they were retrieved and in 40 left in the abdomen. Twelve patients developed complications. Percutaneous drainage was successful in 2 with serous collections. Two patients with abdominal abscesses were reoperated, stones retrieved and the abdomen drained. One patient developed an intestinal obstruction due to a stone in the ileum. One patient who had a cholecystectomy in another hospital developed a paraumbilical tumor. At reoperation a stone was retrieved. In another six patients, stones were found in port sites. Stones lost into the abdomen should be removed because of their potential morbidity, especially if they are large or if infection is present in the gallbladder at the time of initial surgery. There is no indication for routine conversion to open surgery when stone spillage occurs, although patients should be informed to avoid legal consequence, and to hasten early diagnosis of later complications.

[Coexistence of renovascular hypertension and pheochromocytoma. Description of 2 clinical cases]. / Coesistenza di ipertensione nefrovascolare e feocromocitoma. Descrizione di due casi clinici.

The two unusual clinical cases described here illustrate the importance of correct application of clinical methodology. Two patients, a 55-year-old man and a 50-year-old woman, presented with severe hypertension due to the coexistence of renal artery stenosis and pheochromocytoma. Their symptoms were indicative of renovascular hypertension which was verified by the finding of extremely elevated plasma renin activity and angiographic detection of critical renal artery stenosis. Further consideration of specific clinical findings led to the suspicion of coexisting pathologies: the detection of elevated plasma catecholamine levels and abdominal computed tomography and iodobenzylguanidine imaging confirmed the presence of pheochromocytoma. The first patient repeatedly refused surgical treatment and died after 9 months; the second patient recovered after undergoing combined nephrectomy and tumor removal. These cases underscore the importance of a carefully planned sequence of studies in patients presenting with uncommon or equivocal clinical manifestations, particularly when conclusive diagnosis is essential to successful treatment.

[Prospective evaluation of the captopril test in diagnosing renal artery stenosis in hypertensive patients]. / Valutazione prospettica del test al captopril nella diagnosi di stenosi di arteria renale in soggetti ipertesi.

In order to verify the utility of the captopril test (CT) in diagnosing renal artery stenosis we performed a prospective study in 94 consecutive patients (40 females, 54 males, mean age 52.4 +/- 12.3 years) suspected of having renovascular hypertension and with a serum level of creatinine < 2 mg/dl. Antihypertensive drugs were withdrawn one week before the CT or, if this was considered unsafe, patients were treated with nifedipine or diltiazem (53 subjects; 56.4%). We used renal angiography and the Muller criteria to interpret the CT. Our results were as follows: sensitivity, 92%; specificity, 96%; positive predictive value, 88%; and negative predictive value, 97%. In our study a simplified criterion for positive CT-postcaptopril plasma renin activity > 10 ng/mL/h-provided a similar diagnostic value. We conclude that the captopril test is a useful screening test for the detection of renal artery stenosis in selected hypertensive patients and that it can also be reliably performed in patients who are taking calcium antagonists.

[Comparison of the efficacy of monotherapy with a beta-blocker, a diuretic, and ACE inhibitors in the control of blood pressure during stress]. / Confronto dell'efficacia delle monoterapie con beta-bloccante, diuretico, ACE-inibitore nel controllo dei valori pressori durante stress.

In order to compare the efficacy of beta-blocking, diuretics and ACE-inhibiting monotherapy in controlling the blood pressure increase to stress, a study was conducted on 30 subjects (10 treated with atenolol, 10 with hydrochlorothiazide/amiloride combination, 10 with enalapril) with mild or moderate essential hypertension whose resting blood pressures were normalised by therapy. In the 3 groups of subjects blood pressure values at rest, during mental stress, static and dynamic exercise did not significantly differ before antihypertensive therapy. Atenolol and enalapril significantly reduced systolic and diastolic pressure below pretreatment values throughout and immediately after each test, differing from diuretic therapy which did not show any significant reduction in diastolic rises at the peak of hand-grip or in both systolic and diastolic pressures at the highest work-loads during dynamic exercise. In the recovery period of the exercise cycle test diuretics also produced a later normalisation of diastolic pressure. In conclusion, beta-blockers and ACE-inhibitors seem to be more effective than diuretics in the control of the blood pressure response to stress in hypertensive patients, suggesting that these drugs are the first choice treatment of mild to moderate hypertension.

[Severe hypopotassemia and rhabdomyolysis in a normotensive subject after use of a nasal spray containing 9-alpha-fluoroprednisolone]. / Severa ipopotassiemia e rabdomiolisi da uso di spray nasale contenente 9-alfa-fluorprednisolone in soggetto normoteso.

We report the case of a 16-year-old boy who was admitted to our hospital for acute urinary retention, flaccid paralysis of the legs and arms and rhabdomyolysis due to a nasal spray containing 9-alpha-fluoroprednisolone. In our normotensive subject, rhabdomyolysis occurred after vigorous physical activity performed before the administration. The case emphasizes the need to avoid the use of 9-alpha-fluoroprednisolone considering its intense mineralocorticoid activity.

Beta-blocker versus diuretic for control of the blood pressure response to stress in hypertensive patients.

To compare the antihypertensive effects of beta-blockers and diuretics on the blood pressure increase to stress, a randomized single-blind crossover study was performed in 27 patients with mild or moderate hypertension. At the initial examination and after two subsequent periods of therapy with 100 mg atenolol or with a combination of 50 mg hydrochlorothiazide and 5 mg amiloride hydrochloride, once a day, blood pressure and heart rate were measured at rest, during mental arithmetic, sustained handgrip and cycloergometric test. Both treatment significantly decreased supine and standing systolic and diastolic pressure at rest, during and immediately after mental stress and isometric exercise, with the reduction of diastolic pressure significantly greater after atenolol. During dynamic exercise, systolic and diastolic pressures were significantly decreased by diuretics at the lowest work-load only, whereas beta-blocker caused significant and greater blood pressure reductions throughout the exercise. The combination of two classes of drug normalized resting blood pressure in 8 of 9 subjects in which the monotherapy had failed to obtain values less than 140/90 mmHg and gave a better control of systolic and diastolic pressures throughout all the stress tests. It is concluded that atenolol is more effective than diuretics during stress, suggesting that beta-blocking drugs are the first choice treatment for mild to moderate hypertension and that when the antihypertensive effect of a single agent is insufficient, a combination of beta-blockers and diuretics is also effective during stress.